Akriti Sinha, MD

Psychiatrists are called on to help patients with an array of stubborn mental health illnesses. Some of the most challenging to treat are also the deadliest: eating disorders. Characterized by a persistent disturbance of eating that impairs health and psychosocial functioning, these disorders include anorexia nervosa, avoidant/restrictive food intake disorder, binge eating disorder, bulimia nervosa, pica, and rumination disorder. Too often, their outcomes are tragic. Anorexia nervosa is associated with the highest mortality rate of all psychiatric disorders, with fatal outcomes observed in approximately 10% of cases, primarily from 

Recently I watched the 2017 Netflix film 

, a semi-autobiographical story about a 20-year-old named Ellen and her journey to recovery from anorexia nervosa. It is based on the experiences of Marti Noxon, the film’s director, and Lily Collins, the actress who plays Ellen. The film starts with a written warning of triggers, a warning that should be taken seriously by anyone likely to be upset or encouraged by the behavior.

In the film, Ellen is a cynical, artistic young woman whose anorexia has made her life unmanageable. Forced to see a new doctor by her nervous stepmother, she ends up in an inpatient rehab unlike any other she has been in before: A house with 7 young individuals supervised by a blunt house manager and an unconventional clinician—Dr Beckman, played by Keanu Reeves. The young patients are diverse, both demographically and in terms of their eating disorders. The housemates include a Black female with binge eating disorder, a White female with bulimia nervosa, a British white male with anorexia, and a pregnant White female with anorexia (who has a miscarriage). The movie’s diverse cast reflects the epidemiology of eating disorders, which affect individuals of various ages, sizes, socioeconomic statuses, gender identities, races, and cultural and ethnic backgrounds.

When we meet Ellen, her weight has fallen dangerously low; she exercises excessively, shows obsessive attention to counting calories, and hints at a preoccupation with thoughts of food, consistent with the diagnosis of anorexia nervosa. Another character with anorexia nervosa also feels distressed when she learns the number of calories that she has received through a feeding tube. Ellen wears loose clothing, which is a warning sign for anorexia, since loose outfits hide weight loss and can help the wearer 

 She reassures her sister and herself that she has it all under control, a common belief among patients with eating disorders.

Another character, Anna, has bulimia nervosa. She engages in the purging behavior of vomiting, uses laxatives, and exercises secretly. Anna’s experience of binge eating is not shown, despite binging being a core component of bulimia. Often, individuals with binge eating disorder are not given significant attention, even though this is the most common eating disorder in the 

The movie also shows the exasperation of the patients’ families. Ellen’s stepmother and stepsister exemplify the fallacies that so many individuals have about eating disorders. “Why don’t you just eat?” Ellen’s sister asks in exasperation, while her stepmom gibes: “Do you think this is beautiful?” The pathogenesis of eating disorders is complex and attributable to a combination of genetic, environmental, and biological factors, including dysregulation of homeostatic drive and the 

 Like most mental illnesses, childhood adversity plays an important role. Ellen’s mother came out as gay when Ellen was 13 years old and now lives in Phoenix, running a horse therapy farm with her partner. We do not see the father; he seems to be physically and emotionally absent. The child with the eating disorder is often expressing dysfunction within the family system through her behaviors and symptoms, as Ellen exemplifies.

Ellen and her peers are shown in a residential group home in which they have a lot of say in their treatment. This may not be a realistic portrayal. Treatment of eating disorders generally involves an interdisciplinary team; this team includes a mental health clinician, dietitian, and a general medical clinician. Although Beckham conducts individual and family sessions, the treatment approach overall does not match with commonly used, well-established therapy plans like cognitive behavioral therapy, psychodynamic psychotherapy, or the Maudsley model of 

Beckham has a tough tone: He calls Ellen’s attitude “childish and cowardly” and tells her, “You know how [to recover].” He makes statements such as, “Stop waiting for life to be easy. Stop hoping for somebody to save you....Face some hard facts and you could have an incredible life.” These ideas suggest that Ellen needs to simply use her willpower and decide to get better, which is not a realistic vision for recovery. For Ellen, it was not about eating, it was about deciding to choose life. To achieve long-term recovery, the focus needs to be redirected to the underlying emotional, cultural, psychological, and spiritual issues.

Several noteworthy scenes have stayed with me: The emotional scene when Ellen asks her mother to feed her like a baby; the thousands of emotions that trace across her face every time she steps on the scale to be weighed; and the way she constantly circles her upper arm with her middle finger and thumb (a practice known as body checking). At the end of her family therapy, Ellen states, “I’m sorry that I’m not a person anymore; that I’m a problem.” This is touching, because medical professionals and family can lose sight of the fact that their patients are individuals with feelings, not just diagnoses.

Noxon’s film does an incredible job of portraying the nuances of this complicated character living with an even more convoluted illness while also developing the world around her. 

 finds the humor in its material, the absurdity of real-life mixed in with real dangers. Collins, who has been honest about her own experiences with eating disorders, channels that struggle into a fine performance.

In 1983, when Karen Carpenter died of anorexia, the general public expressed shock that someone could starve themselves to death. In the 1990s, unfortunately, skinny was the overwhelming female beauty standard. Now some websites glamorize anorexia, advising readers on how to avoid eating, and some show so-called 

 pictures on Instagram. The more we talk about eating disorders as a serious mental illness, the more we can break down the walls of stigma that keep individuals from seeking the early intervention that improves prognosis.

is chief resident physician of psychiatry at the University of Missouri–Columbia.

1. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. 

. National Eating Disorders Association. Accessed April 21, 2021. 

. National Eating Disorders Association. Accessed April 21, 2021. 

4. Treasure J, Claudino AM, Zucker N. Eating disorders. 

5. Zipfel S, Giel KE, Bulik CM, et al. Anorexia nervosa: aetiology, assessment, and treatment. 

Articles

A television drama looks at eating disorders from the patient, physician, and family perspectives. What does it get right—and wrong?

Breaking the Skinny Standard: Anorexia on Screen 

When Amazon Prime decided to base a television series on selected stories from the “Modern Love” column of The New York Times, I was excited. I had been an avid reader of the column, in which individuals reflect on the intricate nature of human relationships. The episode that struck me most was “Take Me As I Am, Whoever I Am,” 

based on the essay written by Terri Cheney in 2008

 Then an entertainment lawyer, Terri wrote about her struggles with ultradian bipolar disorder, revealing how she hid her condition from her friends before ultimately going public.

In the series, Terri is played by Anne Hathaway. The Oscar-winning actress takes the viewer through the roller coaster of bipolar highs and lows. The episode begins with Lexi (Hathaway) during a manic high at a supermarket. She sports loud makeup, sequins, and bright clothes. She is instantly drawn to a man named Jeff and lands herself a date with him that week. The action segues into a flash-mob dance reminiscent of a scene in the movie 

As might be expected, the high does not last. As soon as Lexi reaches home, she abruptly sinks into depression and curls up in a fetal position, almost catatonic in her bed. While she does manage to wake herself up for the date, she appears slow, dysphoric, withdrawn, and unkempt, making Jeff wonder if she has a twin.

A few mornings later, Lexi wakes up—euphoric again—to the sound of birds chirping, and she calls Jeff for another date. However, by the time he arrives that night, she has flipped again, going from dancing around her apartment to sobbing uncontrollably on the bathroom floor. When Jeff walks away, she decides things need to change. She needs to give everyone a chance to know the real Lexi.

The episode illustrated how stigma often prevents individuals from getting the psychiatric help they need. Particularly unusual was the portrayal of a high-functioning lawyer with ultra-ultra rapid cycling (ultradian) bipolar disorder, an uncommon illness for even psychiatrists to see and diagnose. Lexi had almost no baseline or a euthymic phase.

As a portrayal of bipolar disorder, the episode has both strong and weak points. Hathaway’s portrayal of Lexi’s depression makes you feel empathetic. Crumpled on her bathroom floor in tears, hopeless and terrified, Lexi is a realistic portrayal of many patients’ experiences. Lexi’s mania, however, looks as glamorous as a Hollywood movie. She is super-productive and euphoric, with no impairment or mixed symptoms. Unfortunately, many patients will not be able to relate.

Pluses and minuses aside, it is heartening to think that viewers will see and empathize with Lexi’s struggles. Ultradian bipolar disorder can be difficult to recognize, even for psychiatrists, and it can be a controversial 

 While 12% to 24% of patients with bipolar disorder experience rapid cycling (defined as 4 or more mood episodes in a year), the ultradian form is characterized by multiple episodes in a day. Some psychiatrists would prefer to classify it as a mixed state. Ultradian might also be mistaken for borderline personality disorder (BPD), but there are ways to distinguish them. For instance, mood cycling in BPD is closely tied to events in patients’ emotional lives, so it may appear random. In contrast, the underlying chemical disturbance in ultradian bipolar disorder leads to more regular mood cycling.

Despite its rarity, ultradian has been on psychiatrists’ radar for decades, and good treatment options are available. Robert M. Post, MD, and colleagues first described 

 Anticonvulsants like valproic acid and carbamazepine may be more effective for treatment than lithium. It is also important to reduce triggering factors like antidepressants, drugs of abuse, thyroid abnormalities, and irregular sleep schedules. There have been promising results with calcium channel blockers like 

In the episode’s final scene, Lexi finally opens up about her condition to a coworker. It is a powerful moment in which she likens the cathartic experience to an elephant lifting its foot off her chest. After a trial of several medications and electroconvulsive therapy, Lexi finds a new stability. She is ready to begin a new chapter in her life.

Cheney’s column and the episode both end with 

: “I’ve finally accepted that there is no cure for the chemical imbalance in my brain, any more than there is a cure for love.”

An earlier version of this article was posted ahead of print on March 9, 2021, with the following title: 

Handling the Highs and Lows of Ultradian Bipolar Disorder—and Love

1. Jones D. Modern Love: coming out as bipolar in Modern Love and reliving it on TV. The New York Times. October 18, 2019. Accessed February 15, 2021. 

https://www.nytimes.com/2019/10/18/style/anne-hathaway-modern-love-terri-cheney.html

2. Bauer M, Beaulieu S, Dunner DL, Lafer B, Kupka R. Rapid cycling bipolar disorder—diagnostic concepts. Bipolar Disord. 2008;10(1 Pt 2):153-162. doi:10.1111/j.1399-5618.2007.00560.x

3. Kramlinger KG, Post RM. Ultra-rapid and ultradian cycling in bipolar affective illness. Br J Psychiatry. 1996;168(3):314-323. doi:10.1192/bjp.168.3.314

4. The Carlat Psychiatry Podcast. Word of the day: ultradian cycling. Carlat Publishing. July 4, 2020. Accessed February 15, 2021. 

https://www.thecarlatreport.com/blog/word-of-the-day-ultradian-cycling/

5. Cheney T. Modern Love: take me as I am, whoever I am. The New York Times. January 13, 2008. Accessed February 15, 2021. 

https://www.nytimes.com/2008/01/13/style/modern-love-take-me-as-i-am-whoever-i-am.html

“As soon as Lexi reaches home, she abruptly sinks into depression and curls up in a fetal position, almost catatonic in her bed.”

Finding Love Among the Highs and Lows of Ultradian Bipolar Disorder

When Amazon Prime decided to stream selected stories from the “Modern Love” column of 

, I was excited. I had been an avid reader of this section, where individuals reflect on the intricate nature of human relationships. The episode that struck me was “Take Me As I Am, Whoever I Am,” based on 

the essay written by Terri Cheney in 2008

In the television series, Terri is played by Anna Hathaway, the Oscar-winning actress who takes you through the roller coaster of bipolar highs and lows. The episode starts with Lexi (Hathaway) during her manic high at a supermarket. She sports loud makeup, sequins, and bright clothes. She is instantly drawn to a man named Jeff and lands herself a date with him that week. The scene breaks into a flash mob dance reminiscent of the movie 

The high does not last. As soon as Lexi reaches home, she abruptly sinks into depression and curls up in a fetal position, almost catatonic in her bed. While she does manage to wake herself up for the date, she appears slow, dysphoric, withdrawn, and unkempt, making Jeff wonder if she has a twin.

A few mornings later, she wakes up, euphoric again, to the sound of birds chirping and calls Jeff for another date. However, by the time he arrives that night, she has flipped again, going from dancing around her apartment to sobbing uncontrollably on the bathroom floor. When Jeff walks away, she decides that things need to change. She needs to give everyone a chance to know the real her.

The episode illustrated how the stigma of mental illness keeps people from getting the help they need. What was unique was the portrayal of a high-functioning lawyer with ultra-ultra rapid cycling (ultradian) bipolar disorder, an uncommon diagnosis for even psychiatrists to make or witness. Lexi almost had no baseline or a euthymic phase. As a portrayal of bipolar disorder, the episode has its strong and weak points. Hathaway’s portrayal of Lexi’s depression makes you feel empathetic. Crumpled on her bathroom floor in tears, hopeless and terrified, Lexi is a realistic portrayal of many patients’ experiences. Lexi’s mania, however, looks as glamorous as a Hollywood movie. She is super productive and euphoric with no impairment or mixed symptoms. Unfortunately, many patients will not be able to relate.

Pluses and minuses aside, it is heartening to think that viewers will see and sympathize with Lexi’s condition. Ultradian can be difficult to recognize, even for psychiatrists, and it can be a controversial 

 While 12% to 24% of patients with bipolar disorder experience rapid cycling (a total of 4 or more mood episodes in a year), ultradian is characterized by multiple episodes in a day. Some psychiatrists would prefer to classify it as a mixed state. Ultradian might also be mistaken for borderline personality disorder (BPD), but there are ways to distinguish the disorders. BPD mood cycling is closely tied to events in patients’ emotional lives, so it may appear random. In contrast, the underlying chemical disturbance in ultradian bipolar disorder will lead to more regular mood cycling.

 Anticonvulsants like valproic acid and carbamazepine might be more effective for treatment than lithium. It is also important to reduce triggering factors like antidepressants, drugs of abuse, thyroid abnormalities, and irregular sleep schedules. There are promising results on calcium channel blockers like 

In the final scene of the show, Lexi finally opens up about her condition to a coworker. It is a powerful moment in which she describes the cathartic experience as an elephant lifting its foot off her chest. After a trial of several medications and electroconvulsive therapy, she finds a new stability. She is ready to begin a new chapter in her life.

Cheney’s column and the episode end with 

is chief resident physician of psychiatry at the University of Missouri-Columbia.

1. Jones D. Coming out as bipolar in modern love and reliving it on TV. 

. October 18, 2019. Accessed February 15, 2021. 

2. Bauer M, Beaulieu S, Dunner DL, et al. Rapid cycling bipolar disorder—diagnostic concepts. 

3. Kramlinger KG, Post RM. Ultra-rapid and ultradian cycling in bipolar affective illness. 

Word of the day: ultradian cycling. Published July 4, 2020. Accessed February 15, 2021.

5. Cheney T. Take me as I am, whoever I am. 

. January 13, 2008. Accessed February 15, 2021.

A high-powered lawyer faces her toughest opponent yet: mental illness stigma.